Incidence of fatal and non-fatal pulmonary thromboembolism after removal of tunnelled central venous haemodialysis catheters without ultrasound scan and anticoagulation.

BACKGROUND: Catheter related thrombosis is a common complication of tunnelled central venous catheter (TCVC) usage. There are concerns that TCVC removal could dislodge a thrombus to cause pulmonary thromboembolism (PE). The incidence of PE following TCVC removal is unclear and so the aim of this study was to investigate the incidence of PE and whether it is high enough to warrant screening with ultrasound with a view to systemic anticoagulation prior to TCVC removal. METHODS: 1102 consecutive TCVC removals without ultrasound and systemic anticoagulation were included in this retrospective study. Data were extracted from electronic health records. Measures to identify PE events included: deaths, computed tomography pulmonary angiogram (CT-PA), isotope lung perfusion scans and D-dimers blood tests within 7 days of removal. RESULTS: Of the 1102 TCVC removals, the mean age of patients was 56.9 years and 57.3% were male. The primary renal diagnosis for 24.5% of patients was diabetic nephropathy. There were seven deaths following removal, none of which had PE as a contributing cause on review of their clinical history and death certificates. Five CT-PAs and one isotope lung perfusion scan were carried out in the 7 days after TCVC removal and none had a positive finding of PE. Three patient had D-dimers measured in blood within 7 days and none of these patients were subsequently diagnosed with PE. CONCLUSIONS: There was no evidence of fatal or non-fatal PE's occurring in the 7 days following TCVC removal. This would support the practice of removing TCVCs without the need for ultrasound screening and without a period of systemic anticoagulation.

Long-Term Echocardiographic and Clinical Outcomes After Invasive and Non-Invasive Therapies for Sub-Massive and Massive Acute Pulmonary Embolism.

AIM: Acute pulmonary embolism (PE) is a significant cause of mortality in the hospital setting. The objective of this study was to outline the long-term outcomes after surgical and non-surgical management for patients with massive and submassive PE. METHODS: Population cohort observational study evaluating all patients who presented to three tertiary hospitals in the state of Western Australia with access to cardiothoracic services over 5 years (2013-2018). Reviewed notes of all patients as well as radiology, linked mortality data and all available echocardiography studies at the primary hospital. RESULTS: In total, 245 patients were identified, of which 41 received surgical management and 204 non-surgical management; demographic data was similar. Clinically, the surgical group had higher rates of shock requiring vasopressors, severe bradycardia, or cardiopulmonary resuscitation prior to intervention. The 28-day mortality was not statistically significantly different between the surgical embolectomy group (2/41 [4.2%]) and the non-surgical group (17/201 [8.3%]) (p=0.382). There was no difference in 12-month mortality, including when this was adjusted for vasopressors, right ventricular (RV) strain, troponin, and brain natriuretic peptide. In the massive PE sub-group, 28-day mortality was not significantly different: 2/29 (6.9%) surgical group vs 7/34 (20.2%) non-surgical group (p=0.064). Higher rates of severe RV impairment and dilatation were present in the surgical group. All patients with available echocardiography studies at outpatient follow-up returned to normal or mild RV impairment. CONCLUSION: Patients who presented with massive or submassive PE had similar outcomes whether treated with surgical or non-surgical management. Surgical embolectomy is a safe option in a cardiothoracic centre setting.

Clinical decompensation after trauma laparotomy: It's probably not a pulmonary embolus.

Introduction Computed Tomography (CT) to rule out pulmonary embolus (PE) is often ordered during post-trauma laparotomy clinical decompensation (CD) involving fever, tachycardia, tachypnea, and/or leukocytosis. We hypothesize this diagnostic modality is low-yield in the postoperative period when surgery-related sequelae are more probable. Methods This is a single-center retrospective cohort study of patients who underwent trauma laparotomy and had subsequent CT for CD from March 19, 2019 to June 30, 2022. Descriptive statistics and multiple logistic regression were performed. The primary outcome was saddle and lobar PE incidence. Results 1032 adult patients underwent trauma laparotomy with 434 undergoing CT for CD: 137 CT abdomen and pelvis only, 30 CTPE, 265 both. The majority (80.2 %) was male, age 33[interquartile range (IQR) 24-45], suffered penetrating mechanism (57 %), and had ISS 23[IQR16-30]. Injuries at laparotomy included 47 % solid organ, 62 % GI tract, 7 % biliary, 11 % vascular, and 42 % other. 176 (41 %) required damage control laparotomy. Median time to CT post-laparotomy was 174 h [111-235] with saddle and lobar PE in 3 (1 %), peripheral PE 18 (5 %), and abdominal abscess, leak, fluid, or pseudoaneurysm in 222 (51 %). Clinical management was altered (40 %) by antibiotics, therapeutic anticoagulation, drainage, aspiration, filter, thrombectomy, or surgical operation. Patients for whom CT findings changed management were more likely to have had GI tract surgery (69% vs 57 %, p = 0.021), higher white blood cell (WBC) (16.4 [13.1-20.5] vs 15.1 [9.9-19.5], p = 0.002), more hours between CT and laparotomy (184 [141-245] vs 162 [89-230], p = 0.002), and lower mortality (2% vs 8 %, p = 0.008). In-hospital mortality was 5 %; none were PE-related. Predictors of clinical intervention required based on CT imaging were GI tract injury (AOR: 1.65, p = 0.0182), and elevated WBC (AOR: 1.038, p = 0.010 Conclusion Saddle and lobar PE incidence post-trauma laparotomy is low. SIRS-type symptoms prompting postoperative CT commonly have no procedural or antibiotic requirement. Postoperative decompensation is more likely related post-operative complications, and less likely a PE.

Transcatheter Aspiration and Mechanical Embolectomy of an Intracardiac Mass.

The management of pulmonary embolus and intracardiac masses is rapidly evolving with the availability of transcatheter aspiration devices. We describe the utility of a transcatheter aspiration device in management of a patient with pulmonary embolus and a right atrial mass in transit after spinal surgery where a topical hemostatic agent was used to control intraoperative bleeding.

Anticoagulation Management Post Pulmonary Embolism.

Pulmonary embolus (PE) carries a significant impending morbidity and mortality, especially in intermediate and high-risk patients, and the choice of initial anticoagulation that allows for therapeutic adjustment or manipulation is important. The preferred choice of anticoagulation management includes direct oral anticoagulants. Vitamin K antagonists and low-molecular-weight heparin are preferred in special populations or selected patients such as breastfeeding mothers, those with end-stage renal disease, or obese patients, among others. This article reviews the primary and longer-term considerations for anticoagulation management in patients with PE and highlights special patient populations and risk factor considerations.

Achieving durable compliance with venous thromboembolism prophylaxis in bariatric surgery: 3-year data from a major academic medical center.

BACKGROUND: Metabolic and bariatric surgery (MBS) venous thromboembolism (VTE) prescribing practices vary widely. Our institutional VTE prophylaxis protocol has historically been unstandardized. OBJECTIVES: To create a standardized MBS VTE prophylaxis protocol, track protocol compliance, and identify barriers to protocol compliance and address them with Plan-Do-Study-Act (PDSA) cycles. SETTING: Single Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital. METHODS: We conducted a retrospective study for all patients undergoing MBS (January 2019 to September 2022). A multidisciplinary group of bariatric clinicians reviewed literature and developed the following standardized VTE prophylaxis protocol: 5000 units preoperative subcutaneous (SC) heparin within 60 minutes of anesthesia induction and postoperative 40 mg SC low molecular weight heparin (LMWH) within 24 hours of surgery. This protocol was distributed to relevant clinical stakeholders. We assessed monthly compliance rates through chart review. Goal compliance was ≥90%. We identified sources of noncompliance and addressed them with PDSA methodology. RESULTS: A total of 796 patients were included. Preoperative heparin administration increased from a mean of 47% (107/228) preintervention to 96% (545/568) postintervention (P < .0001), and postoperative LMWH administration increased from 71% (47/66) to 96% (573/597, P = .0002). These compliance rates were sustained for 3 years. Barriers to protocol noncompliance included order set timing errors (n = 45), surgeon error (n = 44), surgeon discretion (n = 40), and nursing error (n = 20). No change in bleeding or VTE rates was observed. CONCLUSIONS: Developing a standardized VTE prophylaxis protocol, monitoring process measures, and engaging relevant stakeholders in PDSA cycles resulted in drastic and durable improvement in VTE prophylaxis compliance rates.

Causal relationships between risk of venous thromboembolism and 18 cancers: a bidirectional Mendelian randomization analysis.

BACKGROUND: People with cancer experience high rates of venous thromboembolism (VTE). Risk of subsequent cancer is also increased in people experiencing their first VTE. The causal mechanisms underlying this association are not completely understood, and it is unknown whether VTE is itself a risk factor for cancer. METHODS: We used data from large genome-wide association study meta-analyses to perform bidirectional Mendelian randomization analyses to estimate causal associations between genetic liability to VTE and risk of 18 different cancers. RESULTS: We found no conclusive evidence that genetic liability to VTE was causally associated with an increased incidence of cancer, or vice versa. We observed an association between liability to VTE and pancreatic cancer risk [odds ratio for pancreatic cancer: 1.23 (95% confidence interval: 1.08-1.40) per log-odds increase in VTE risk, P = 0.002]. However, sensitivity analyses revealed this association was predominantly driven by a variant proxying non-O blood group, with inadequate evidence to suggest a causal relationship. CONCLUSIONS: These findings do not support the hypothesis that genetic liability to VTE is a cause of cancer. Existing observational epidemiological associations between VTE and cancer are therefore more likely to be driven by pathophysiological changes which occur in the setting of active cancer and anti-cancer treatments. Further work is required to explore and synthesize evidence for these mechanisms.

ECG Features of Pulmonary Embolism in a Patient With Normal D-Dimer and Hypoxia.

Pulmonary embolism is a life-threatening condition that requires urgent treatment. We present the case of a 76-year-old male referred to our medical team with dyspnoea, shortness of breath on exertion, and chest pain. Upon further questioning, the patient reported a two-week history of right-sided parasternal pleuritic chest pain without radiation. He denied any history of haemoptysis, calf swelling or pain, recent surgery, and reduced mobility. The patient had a medical history of bilateral cataracts, glaucoma, and hypertension. Clinical examination was unremarkable except for requiring 2L/minute supplemental oxygen to maintain an oxygen saturation of 94%, and blood tests were unremarkable, including a normal D-dimer. Chest radiography revealed no obvious pathological findings. However, the electrocardiogram showed a right bundle branch, sinus tachycardia, and an S1Q3T3 pattern. A computed tomography pulmonary angiogram confirmed pulmonary emboli within the right lower lobe segmental artery, extending into the bilateral basal segmental branch and posterior basal segmental branch. The patient was commenced on low molecular weight heparin initially followed by rivaroxaban 20 mg once daily. This case highlights the importance of having a high degree of suspicion for pulmonary embolism, and D-dimer is an important screening test that can be normal.

Cardiac Point-of-Care Ultrasound (P.O.C.U.S.) Utilization for Hospitalists in the Assessment of Patients with Cardiac Complaints: An Educational Overview.

The use of cardiac point-of-care ultrasound (P.O.C.U.S.) is underutilized in the field of internal medicine for the assessment of patients with cardiac complaints. Numerous studies in emergency medicine, anesthesia, and critical care have demonstrated the successful application of cardiac P.O.C.U.S. in resident and attending physicians with limited prior exposure. This article review overviews the practical implementation of cardiac P.O.C.U.S. for hospitalists by discussing proper technique and assessment for common pathology seen in the medical ward setting. We describe how to assess for left ventricular (LV) systolic function, right ventricular (RV) systolic function, suspected acute coronary syndrome (ACS), post-myocardial infarction (MI) complications, suspected pulmonary embolus, and assessment of intravascular volume status. In each section, we overview the pertinent literature to show how cardiac P.O.C.U.S. has been used to directly impact patient care.

Percutaneous endovascular vacuum assisted removal of intracardiac lesions using the AngioVac system: A real-world experience.

The AngioVac© system (AngioDynamics, Latham, NY, USA) is a percutaneous catheter-based approach indicated for the removal of unwanted intravascular material from venous circulation and offers a safe alternative to conventional surgical extraction. This series describes various pathologies that were high risk for surgical management in which AngioVac© proved to be a suitable alternative. Learning objectives: Demonstrate the utility of minimally invasive techniques for removal of unwanted venous material using percutaneous endovascular vacuum assisted aspiration. Formulate a new treatment algorithm in the management of unwanted right-sided material.

Pulmonary Vein Thrombosis and Pulmonary Embolus in a Pregnant Patient: A Case Report.

We report a case of a pregnant woman who presented to the emergency department complaining of dyspnea and syncope and was ultimately diagnosed with pulmonary vein thrombosis and a saddle pulmonary embolus on computed tomography pulmonary angiography. Proper identification is critical for prompt management to avoid significant life-threatening sequela.

Epithelioid Hemangioendothelioma Presenting as Necrotizing Pneumonia.

Epithelioid hemangioendothelioma (EHE) is a very rare vascular neoplasm that is often asymptomatic. A 40-year-old woman presented to the emergency department for evaluation of a nonproductive cough, chest pain, and dyspnea. A chest computed tomography angiography (CTA) demonstrated necrotizing pneumonia, a loculated left-sided pleural effusion, and an acute pulmonary embolus. She was started on broad-spectrum intravenous antibiotics and heparin infusions, and a chest tube was placed. After minimal improvement in her pleural effusion following instillation of fibrinolytics, she underwent video-assisted thoracoscopic surgery with decortication, and a pleural biopsy was performed. Her presenting symptoms resolved shortly thereafter. Following discharge, surgical pathology resulted in a diagnosis of EHE. She was not a candidate for surgical resection and remained under surveillance. A year later, she was found to have metastatic disease, and radiotherapy was initiated. Our case, which presented as necrotizing pneumonia associated with pulmonary EHE, highlights the challenges in diagnosing this disease given its extreme rarity and discusses its management.

Causal relationships between risk of venous thromboembolism and 18 cancers: a bidirectional Mendelian randomisation analysis.

Background: People with cancer experience high rates of venous thromboembolism (VTE). Additionally, risk of subsequent cancer is increased in people experiencing their first VTE. The causal mechanisms underlying this association are not completely understood, and it is unknown whether VTE is itself a risk factor for cancer. Methods: We used data from large genome-wide association study meta-analyses to perform bi-directional Mendelian randomisation analyses to estimate causal associations between genetically-proxied lifetime risk of VTE and risk of 18 different cancers. Results: We found no conclusive evidence that genetically-proxied lifetime risk of VTE was causally associated with an increased incidence of cancer, or vice-versa. We observed an association between VTE and pancreatic cancer risk (odds ratio for pancreatic cancer 1.23 (95% confidence interval 1.08 - 1.40) per log-odds increase in risk of VTE, P = 0.002). However, sensitivity analyses revealed this association was predominantly driven by a variant proxying non-O blood group, with inadequate evidence from Mendelian randomisation to suggest a causal relationship. Conclusions: These findings do not support the hypothesis that genetically-proxied lifetime risk of VTE is a cause of cancer. Existing observational epidemiological associations between VTE and cancer are therefore more likely to be driven by pathophysiological changes which occur in the setting of active cancer and anti-cancer treatments. Further work is required to explore and synthesise evidence for these mechanisms.

Acute Aortic Injury and Bilateral Pulmonary Emboli in the Setting of COVID-19.

In this report, we present the case of a 72-year-old female diagnosed with an aortic dissection variant and bilateral pulmonary emboli (PE) in the setting of Coronavirus Disease of 2019 (COVID-19) infection. The patient was transported from home to the emergency department (ED) via emergency medical services (EMS) with acute chest pain and dyspnea. After arriving at the ED, she was hypoxic on her baseline supplemental O2 requirement and tachycardic and tachypneic. Computed tomography (CT) angiogram of the chest showed evidence of possible thoracic aortic dissection and bilateral PE. The patient was ultimately transported to a tertiary center for operative aortic repair and bilateral embolectomy and, fortunately, survived the procedures. Interestingly, during operative repair of the aorta, no obvious dissection flap was noted, but rather evidence of a limited tear in the intimal layer of the aorta. This is an interesting case as acute aortic injuries in the setting of COVID-19 infection have not been as widely documented as PE in the setting of COVID and highlight the need for further research on the possible association between them.

Contemporary management of intracardiac thrombi: a tale of two clots.

Intracardiac thrombi such as pulmonary emboli represent a high risk of mortality. In this case study, we review two cases of intracardiac thrombi occurring within 24 h of one another and managed differently by the same cardiothoracic surgical team, highlighting the importance of an individualized approach as well as an understanding of current guidelines and contemporary management techniques.

Pulmonary Tumor Embolism Complicated by Metastatic Liver Carcinoma in Female With Primary Breast Carcinoma.

Pulmonary tumor embolism (PTE) is a rare phenomenon typically presenting as dyspnea in cancer patients. Primary pathophysiology is similar to the thromboembolic disease of the pulmonary vasculature, which involves large vessels to small arterioles. This phenomenon occurs mostly in lung, stomach, liver, and breast adenocarcinoma. The symptoms of hypoxemia and the signs of hemodynamic instability and high-resolution computed tomography (CT) scans, along with a histopathological examination, are essential to make a confirmatory diagnosis of pulmonary tumor embolism. However, treatment options to effectively treat pulmonary tumor embolus are limited and still under investigation. We present a rare case of pulmonary tumor embolism in a patient with metastatic liver carcinoma and its management in a female with primary breast carcinoma.

Catheter directed thrombolysis for a pulmonary arterial thrombus on VA ECMO in a child - a case report.

INTRODUCTION: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) as a bridge to cardiac transplantation is considered a high risk support strategy in the paediatric population. METHODS: We describe the case of a 12 year old boy who required V-A ECMO support for rapidly deteriorating cardiomyopathy and developed a massive pulmonary embolus (PE) peri-cannulation. Subsequent investigations were also positive for heparin induced thrombocytopenia. RESULTS: We elected to treat the PE with ultrasound accelerated catheter directed thrombolysis using the advantages of this minimally invasive targeted method to try and resolve the PE and avoid a cerebral haemorrhage, both of which would have taken the patient off the urgent transplant list. CONCLUSION: The PE resolved in 24 h and he went on to receive a cardiac transplant and have a favourable outcome.

Massive Pulmonary Embolus Following a Hemorrhagic Stroke: A Thrombolysis Therapy Dilemma.

Pulmonary embolism varies in presentation with factors such as embolus size and pre-existing comorbidities contributing significantly. Despite the availability of several options to treat pulmonary embolism, these options significantly decrease when a massive pulmonary embolism causes a cardiac arrest in the setting of a recent hemorrhage thalamic stroke. We reviewed the current literature and presented a case report. In addition, we presented seven cases of pulmonary embolus where thrombolysis was used despite an absolute contraindication to thrombolysis, and the patients had successful outcomes.

Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE): Outcomes at 12 months.

OBJECTIVE: To determine the safety and effectiveness of vena cava filters (VCFs). METHODS: A total of 1429 participants (62.7 ± 14.7 years old; 762 [53.3% male]) consented to enroll in this prospective, nonrandomized study at 54 sites in the United States between October 10, 2015, and March 31, 2019. They were evaluated at baseline and at 3, 6, 12, 18, and 24 months following VCF implantation. Participants whose VCFs were removed were followed for 1 month after retrieval. Follow-up was performed at 3, 12, and 24 months. Predetermined composite primary safety (freedom from perioperative serious adverse events [AEs] and from clinically significant perforation, VCF embolization, caval thrombotic occlusion, and/or new deep vein thrombosis [DVT] within 12-months) and effectiveness (composite comprising procedural and technical success and freedom from new symptomatic pulmonary embolism [PE] confirmed by imaging at 12-months in situ or 1 month postretrieval) end points were assessed. RESULTS: VCFs were implanted in 1421 patients. Of these, 1019 (71.7%) had current DVT and/or PE. Anticoagulation therapy was contraindicated or had failed in 1159 (81.6%). One hundred twenty-six (8.9%) VCFs were prophylactic. Mean and median follow-up for the entire population and for those whose VCFs were not removed was 243.5 ± 243.3 days and 138 days and 332.6 ± 290 days and 235 days, respectively. VCFs were removed from 632 (44.5%) patients at a mean of 101.5 ± 72.2 days and median 86.3 days following implantation. The primary safety end point and primary effectiveness end point were both achieved. Procedural AEs were uncommon and usually minor, but one patient died during attempted VCF removal. Excluding strut perforation greater than 5 mm, which was demonstrated on 31 of 201 (15.4%) patients' computed tomography scans available to the core laboratory, and of which only 3 (0.2%) were deemed clinically significant by the site investigators, VCF-related AEs were rare (7 of 1421, 0.5%). Postfilter, venous thromboembolic events (none fatal) occurred in 93 patients (6.5%), including DVT (80 events in 74 patients [5.2%]), PE (23 events in 23 patients [1.6%]), and/or caval thrombotic occlusions (15 events in 15 patients [1.1%]). No PE occurred in patients following prophylactic placement. CONCLUSIONS: Implantation of VCFs in patients with venous thromboembolism was associated with few AEs and with a low incidence of clinically significant PEs.